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Military Social Work in a Time of War
Post Traumatic Stress Disorder and the Ethical Dilemmas of a Veteran Social Worker

Alice Psirakis, LCSW, Director, Veterans and Families Initiative at the Center For Trauma Program Innovation, Jewish Board of Family and Children’s Services

November 2008

Sergeant (SGT) K was a tall, husky, 50-year old Army Reservist, mobilizing for the 3rd time to a combat zone- one tour in Afghanistan and one in Iraq had earned him the diagnosis of Post Traumatic Stress Disorder (PTSD). He suffered from nightmares, intrusive memories and emotional numbing. Yet here he was, having volunteered to deploy once again. He came through our doors as a self-referral, with a primary complaint of insomnia. After an extensive psychosocial history, it was clear that SGT K was suffering from PTSD. But SGT K was insistent on being re-deployed. He had not come to Behavioral Health to get sent back home- he just needed to sleep, he told me, “If I could just sleep, I’ll feel better. My guys need me.” I couldn’t argue with him on that. I also remember telling him that I thought this third deployment was going to be the psychological death of him. SGT K agreed.

Yet SGT K was training effectively with his unit over the past few months- he was mission-oriented, taking care of his lower-enlisted soldiers, and contributed a plethora of knowledge and experience that only a seasoned combat veteran can do. He hadn’t frozen or panicked at all during any simulated fire and training exercises. Other than his insomnia, none of his other PTSD symptoms seemed to be affecting his training at this current time. He wanted to deploy. He felt a responsibility towards his younger, less experienced soldiers who were counting on him during this deployment. And the truth was, no training or behavioral issues of concern had been reported by his leadership thus far. Considering the circumstances, SGT K was functioning extremely well.

After a short-term treatment regiment combining brief psychotherapy and medication management, SGT K was deployed on antidepressants, with instructions to follow up at Combat Stress once he got to Iraq.

My relationship with SGT K reflects the three years I served as the Chief of Behavioral Health Services at one of the largest Army deployment installations from 2004-2007. Day in and day out, my staff and I were tasked with recommending who went to war and who could not. Few people understand the potential ethical conflict that starts brewing here between what I thought a soldier needed and what the Army needed. I was a New York State licensed clinical social worker. A member of NASW whose code of ethics highlights values such as client self-determination. But I was also a Captain in the United States Army- a mental health officer, whose corps motto was, “To Conserve the Fighting Strength.” Years ago, I had sworn to protect my country and serve as a personal reflection of the Army’s core values. My warrior ethos talked about things like, “I will always place the mission first.” Here I was, a social worker plucked out of the civilian world and now mobilized to carry out the Army’s mission and responsible for placing the mission first.

As a military social worker serving in a time of war, it was sometimes unclear to me who I worked for. In my civilian life the answer was easy- the client of course! In the military the answer was much blurrier…where did my clinical loyalties lie? Was I the individual soldier’s advocate? Or was I responsible for advocating on behalf of the Army’s best interests? The reality I discovered was that I worked for both, simultaneously- a balancing act, which proved to be a huge challenge over the course of my tenure at Fort *. I knew in my heart that client-self determination was a paramount part of my professional ethos, but the reality of war dictated otherwise. It didn’t matter if someone wanted to go to war- they just had to.
When we deployed SGT K, we were not saying that he did not have Post Traumatic Stress Disorder- quite the contrary. We were deploying him with PTSD. To many, that is simply unfathomable, and I can understand and respect this view. However, for some it may be less clear how this is even possible in the world of military medicine. The secret is this: It all came down to level of functioning.

The last criterion in the DSM IV-TR for almost all psychological disorders asks: how severely do these symptoms impact the person’s current social and psychological level of functioning? Taking this into consideration, we begin to see how two people with a diagnosis of PTSD may have very different symptom manifestations of it. Some are completely incapacitated by it, while others exhibit fewer symptoms, causing them lesser distress.

There were so many other factors that guided my decision-making: where was this soldier deploying? What was his Military Occupation Specialty; in other words, what was his job? Was he a computer technician who would be inside the wire fixing computers most of the day or was he a gunner going on several patrols a week, probably engaging in live fire exchanges? Was he an administrative clerk who was helping out the Executive Officer all day or was he a truck driver, going back and forth to different bases in Iraq? How savvy was his command about mental health issues and could we trust them to take care of their soldiers if they observed concerning behavior? Was there a combat stress team deploying with this unit? Could the soldier receive his psychotropic medication while deployed? What was the soldier’s previous level of traumatic exposure? What would his potential level of traumatic exposure be in the combat zone this time around? How was he reacting during training here in the States? Was he freezing up during the simulated mortar attacks? Was he withdrawing and isolating himself from his comrades? Was he unable to work as a team player? How disruptive was his hypervigilance to his everyday functioning? The list goes on and on…

The military is a microcosm of American society. It can be difficult to predict human behavior and psychological deterioration in general, much less in a combat zone. The reality is, not everyone is built and wired the same way. We don’t really know why some people will get PTSD, when others, having endured similar trauma do not. We have some ideas, but we don’t truly know why.

I found out that SGT K came by Behavioral Health when he returned from his 3rd tour in Iraq a year later to say hello to us. I was no longer working there when he came in, but often wonder how he is doing now.

Editor’s Note: “Military Social Work in a Time of War” was originally written for the book Hidden Battles on Unseen Fronts: Stories of American Soldiers with PTSD and TBI by Celia Straus for the Armed Forces Foundation, Casemate Publishing, Spring 2009.”